ACLS: Tachycardia

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3 questions

  1. Is the patient in a sinus rhythm?
  2. Is the QRS wide or narrow?
  3. Is the rhythm regular or irregular?

Narrow complex tachycardia

Algorithm for tachycardia with a pulse (Adapted from ACLS 2010)

Narrow Regular Tachycardia

Narrow Irregular Tachycardia

Wide complex tachycardia

Wide Regular Tachycardia[1]

Pulseless: see Adult pulseless arrest

  • Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
  • Stable:
    1. Medications
      • Procainamide (first-line drug of choice)
        • 20-50mg/min until arrhythmia suppressed (max 17mg/kg or 1 gram); then, maintenance infusion of 1-4mg/min x 6hr
          • Alternative administration: 100 mg q5min at max rate of 25-50 mg/min[2]
        • Stop if QRS duration increases >50% or hypotension
        • Avoid if prolonged QT or CHF
        • Favored over Amiodarone in PROCAMIO trial; termination of tachycardia in 67% of procainamide group vs 38% of amiodarone group, adverse cardiac events 9% vs 41%, respectively [3]
      • Amiodarone (agent of choice in setting of AMI or LV dysfunction)
        • 150 mg over 10min (15 mg/min), followed by 1 mg/min drip over 6hrs (360 mg total)[4]
        • Then 0.5 mg/min drip over next 18 hrs (540 mg total)
        • Oral dosage after IV infusion is 400 -800 mg PO daily
      • Consider adenosine
    2. Synchronized Cardioversion (100J)

Wide Irregular Tachycardia

DO NOT use AV nodal blockers as they can precipitate V-Fib
Pulseless: see Adult pulseless arrest

See Also

External Links

Videos

References

  1. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
  2. Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
  3. Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335
  4. Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.